Tweets that make me laugh

First this:

A few items later in my stream was this:

The latter references a new RWJF synthesis on the effects of hospital competition.  The key points:

• Hospital consolidation generally results in higher prices. This is true across geographic markets and different data sources. When hospitals merge in already concentrated markets, the price increase can be dramatic, often exceeding 20 percent.

• Hospital competition improves quality of care. This is true under both administered price systems, such as Medicare and the English National Health Service, and market determined pricing such as the private health insurance market. The evidence is more mixed from studies of market determined systems, however.

• Physician-hospital consolidation has not led to either improved quality or reduced costs. Studies find that consolidation was primarily for the purpose of enhanced bargaining power with payers, and hence did not lead to true integration. Consolidation without integration does not lead to enhanced performance.

For background, Providence was one of the higher cost providers Regence tried to cut out of their network, while Tuality was one of two low cost providers the insurer wanted to keep.  Despite providers being mostly successful in pushing back against that move, it looks like it still struck a nerve...

Republicans and ineffective medicine: The saga continues

The love affair between Republicans and ineffective medicine grows ever more torrid.  Last week it was seeking to undermine the US Preventative Services Task Force, this week it's eliminating health services research.

These attacks on effectiveness research are bizarre.  Republicans claim to support market solutions to health care, but one of the biggest obstacles to that is that people have no idea what they are buying.  Are they buying a Cadillac treatment that delivers 100% satisfaction with no side effects or a 1979 Pinto that will blow up in their face?  When people can't tell the difference between shit and shinola there is no market and you can't have market solutions.   If Republicans are in any way serious about markets they should be advocating for more effectiveness research, not less.

So what explains the attraction?  Why do Republicans seek to protect treatment that doesn't work, like widespread PSA screening?  It's almost like they're afraid of the paradigm of using evidence to guide decisions.  Probably because in the real world so much evidence goes against them...

Providence Rate Filing

I'm normally sympathetic to insurers, but something about this filing rubs me wrong.  Maybe it's because someone thought it was important that everyone know that we're paying an extra 1.1% for women's preventative health services through the ACA, so important that they included it as a line item in the summary.

Or maybe it's because of this:

Instead of estimating an annual factor and blowing it out over 23 months I'm looking at the actual 23 month changes.  I'm comparing that to Providence's selected 7.2% annual factor, which compounds out to 14.3%.  Even against the worst point in 2011 the factor used in the proposed rates is almost double.  Putting it in comparative terms,

Why CCO's may not fail like HMO's

In response to @ChargerJeff, who asked why CCO's would fare any better than HMO's:

HMO's did succeed at cost control, which is a primary purpose of CCO's.  Where HMO's failed was in working cooperatively with doctors and patients, CCO's if they are to last will have to do better.

Reasons to think they will:

• We already have managed care, particularly in OHP.  The distance between where we are and where CCO's are going is shorter than the distance between indemnity plans and HMO's.

• The distance between doctor patient interactions and financial authority is shorter, you're less likely to see the kinds of coverage conflicts for which HMO's were notorious. 

• There is more cost awareness among providers now than there used to be.  Concepts like variation and evidence-based medicine are gaining growing acceptance, even if they are not entirely mainstream.
• Maybe most important, providers have no choice.  CCO's are an attempt to control costs by empowering providers, if they fail the alternative is to control costs by disempowering providers and stripping them of authority over treatment.  Think about the ER restrictions that Washington considered (and that for-profit hospitals have implemented), or more direct interventions in provider pricing.

None of this is to say that CCO's are a sure thing, there's a reason the feds made their funding contingent on results.  But the cost of trying in my view is much smaller than the cost of doing nothing and hoping that a 40 year history of medical inflation will somehow reverse on its own.

Why Evidence Based Medicine is hard

Grrr…  I see the Lund Report carried a press release from a device manufacturer lamenting Medicare's decision to drop coverage of their product for treating chronic lower back pain.  In a different universe that article would have been written by a third party without a direct financial interest and it would have been called, "Clinical studies show that TENS units offer no benefit in treating chronic lower back pain, Medicare to stop wasting tax payer money on them."  But that would be a universe in which health care wasn't eating the economy, not ours.  Why did Lund Report run this?  I'll speculate:

• It was there, and free.  The manufacturer had a financial interest in getting its message out that was not matched by any organization on the other side of the decision.  Nothing from EBM promoters, nothing from those supposedly concerned with Medicare solvency, nothing at all.

•  There is a community with a strong interest in seeing coverage continued:  current and prospective patients.  Which narrative would those people rather see:  That what they've been doing is a waste of time and money, or that government is corrupt and denying them what is rightfully theirs?  Take a guess.

Whatever the reasons, thinking about why this article was run sheds light on why the public has a hard time accepting evidence based medicine.  And no, it has nothing to do with government vs. private insurance.

ps yes, this is another example of Republicans defending ineffective medicine.

Followup on Hollywood

Last year I shot some photos around the Hollywood Theater, trying to understand why people were concerned about the aesthetics of putting an apartment building next door.  The new building isn’t finished, but it’s far enough along to get a sense of the visual impact. Below are side by side comparisons, with the first shot from July of 2011 and the second from May 2012 while construction is in progress.

I still don't get what the fuss was about. The only view negatively impacted was the middle shot from the east side of Sandy around 41st street. I think the apartment building actually improves the view from the west side.

Hmm...

How Effective is Arthroscopic Knee Surgery?
Something to file away for the next time I try to convince someone doctors are no more trustworthy than plumbers.